INTRODUCTION
Self-monitoring of blood glucose (SMBG) provides real-time glucose readings for insulin and diet/exercise adjustments, and thus plays an important role in diabetes management for insulin-treated patients.[1 2 type 1 diabetes is well recognized and is recommended to practice at a certain frequency in different guidelines.[1 2 3 4 type 1 diabetes is not satisfactorily implemented. Many studies have shown a significant gap between recommended SMBG utilization and the real-world practice.[5 6 7
Previous studies shown that many factors have been associated with the frequency of SMBG practice, including gender,[5 6 8 9 5 10 9 5 11 7 12
The information-motivation-behavioral skills (IMB) model of health behavior is a well-researched theoretical model derived from behavioral science.[13 14 15 16 17 18 19 20 21
Guided by IMB model of health behavior, this questionnaire-based survey was designed to study SMBG behavior systemically among a sample of Chinese adult patients with type 1 diabetes .
METHODS
Subjects
Participants were selected from the Guangdong Type 1 Diabetes Mellitus Translational Medicine Study,[22 type 1 diabetes visiting our diabetes clinic from January to March 2012 (n = 63) were consecutively interviewed, except for those newly diagnosed patients (duration <3 months) (n = 6), pregnant patients (n = 2), and patients with severe complications or comorbidities that could not cooperate with the survey (n = 0). Altogether, 55 patients were interviewed, and all of them finished the questionnaire, response rate 100%. Clinical characteristics and frequency of SMBG practicing were collected. The study was approved by the Ethics Committees of the Third Affiliated Hospital of Sun Yat-sen University, and written informed consent was obtained from all participants.
Measures
Measure development
Guided by the theory of IMB model, and referring to an English version of IMB-SMBG questionnaire, a team of endocrinologists together built an IMB-SMBG questionnaire in Chinese. Specific steps are listed in Table 1 . Sample items from each section (translated from Chinese) are shown in Table 2 .
Table 1: Steps of developing the IMB-SMBG questionnaire
Table 2: Sample items from each section of the IMB-SMBG questionnaire
Validity and reliability examination
The first 15 respondents were invited during a diabetes event at our hospital to complete the same questionnaire again 1–3 weeks away from their initial test. The retest response rate was 100%. Test–retest reliability was evaluated using interclass correlation coefficient, which was greater than 0.80 for the total scale (0.92) and the three subscales (0.91, 0.93, and 0.85, respectively), indicating good reliability. Cronbach's alpha, used to test internal consistency, was greater than 0.80 for all subscales (0.86, 0.87, and 0.83, respectively), indicating the scale is internally consistent. Content validation was examined based on correlations between item score and total score of each subscale, proving items had stronger correlation with their own domain (r > 0.50 for 70% of the items, P < 0.001) than the other two.
Questionnaire administration
All respondents completed the questionnaire at the same clinical setting, which was a separate quiet examination room with desks and chairs. Two interviewers were trained before the study to standardize the interview process and interviewed the 55 patients (70 person-times) throughout the study. Brief introduction and necessary explanations about the study purpose and design were given first, written consent was obtained afterward, and then the questionnaire was delivered to the patient for self-completion.
Statistical analysis
Negative (incorrect) and neutral responses to statements in information and motivation sections were coded as “deficient.” Negative responses to statements in behavioral skills section were coded as “deficient.” For each item, proportions of patients that were “deficient” in that particular information/motivation/skill were described. Spearman's correlation was used to analyze relationships between each module and SMBG frequency as well as interrelationships between the three modules. Multiple correlation analysis was used to evaluate the impact of SMBG information, motivation, and behavioral skills as a whole on SMBG frequency.
RESULTS
Sample characteristics and practice of self-monitoring of blood glucose
Clinical characteristics of the survey participants are shown in Table 3 . The median of the average SMBG frequency was 2.00 (0.57, 3.00). The compliance rate of the American Diabetes Association recommendation (to test at least three times daily) was 36.4%, 27.3% of participants tested less often than once a day, 5.4% (n = 3) reported they barely practice SMBG.
Table 3: Characteristics of the survey participants
The information-motivation-behavioral skills analysis
SMBG information deficits, motivation obstacles, and behavioral skill limitations were identified in a substantial proportion of participants [Table 4 ], of which the most prevalent deficits/obstacles/limitations included: The meaning of high blood sugar before exercises (not understood in 50.9% of participants), kind of food that should be taken when blood sugars was low (47.3%); views of the cost of testing being “too expensive” (85.5%) or “painful” (72.7%) if adhered to the doctor's recommendation; feeling difficult to talk with colleges about diabetes (63.6%) and to buy test strips conveniently (58.2%).
Table 4: SMBG information, motivation, and skills deficits among adult patients with type 1 diabetes
The relationship between information-motivation-behavioral skills’ scores and self-monitoring of blood glucose frequency
Scores of SMBG motivation (r = 0.299, P = 0.026) and behavioral skills (r = 0.425, P = 0.001) were significantly correlated with SMBG frequency while score of SMBG information was not (r = 0.255, P = 0.060). Figure 1 shows the relationship between each module and the frequency of SMBG and interrelationship between the modules. The multiple correlation of SMBG information, SMBG motivation, and SMBG behavioral skills with SMBG frequency was R = 0.411 (R 2 = 0.169, P = 0.023). SMBG information, motivation, and skills together accounted for 16.9% of the variation in SMBG frequency among our participants.
Figure 1: Correlations between modules of the IMB-SMBG model and SMBG frequency (*P < 0.05, † P < 0.01). IMB: Information-motivation-behavioral skills; SMBG: Self-monitoring of blood glucose.
DISCUSSION
Guided by the IMB model, the current study developed an SMBG questionnaire, carried out a survey among adult patients with type 1 diabetes in our hospital, and disclosed considerable deficiencies in SMBG information, personal attitudes, and social support in regard to SMBG, and SMBG performing skills among surveyed population. Over half of the patients deemed it was OK to increase exercises when blood glucose is very high. Nearly half of the patients had wrong ideas about the kind of food that should be taken when blood glucose is low and were not against the idea of “feel” the blood sugar without testing. One-fifth did not understand the different meanings of HbA1c and SMBG results and the necessity to practice both. More than half of the patients found that practicing SMBG as recommended would be too expensive, painful, unpleasant, causing anxiety, or interfering with their work. A considerable proportion of patients did not feel support of regular SMBG from surrounding and/or important people. Behavioral skill obstacles mainly included difficulties in talking about having diabetes with workmates and friends, buying test strips conveniently, practicing SMBG painlessly, and keeping glucose meter available. Correlation analysis showed significant correlation between SMBG motivation and frequency as well as between SMBG skill and frequency, and the latter correlation was stronger, suggesting that behavior skills were ultimately the most closely associated factors with SMBG behavior.
The deficiencies revealed were similar with the findings in an earlier study[23 type 1 diabetes , but with a substantial higher proportion of patients having them, especially in the sections of motivation and behavioral skills. In that particular study, mean adherence to recommended SMBG frequency was 90% (n = 208), much higher than the 36.4% recommendation adherence in this study. As could be expected, the mean HbA1c level was lower in the US study than that in this study, 7.3% (56 mmol/mol) versus 7.7% (61 mmol/mol).
All behavioral factors could not be encompassed within one single theoretical model. The IMB model emphasizes the subjective perspectives from the patients without studying the objective requisite conditions in performing the behavior, making it less fitting in study settings where requisite requirements cannot be met at first place. For SMBG behavior, such requirements might include possessing a glucose meter, having been recommended a proper blood glucose monitoring pattern and frequency by a professional, having the basic economic condition or insurance coverage to pay for the monitoring supplies, and reach ability of a diabetes doctor to discuss over the glucose monitoring results. Thus, future studies in attempt to observe or improve SMBG practice among diabetes patients, these and maybe other prerequisites should be investigated in the beginning, especially in developing areas.
Most of the participants in this survey (54/55) were from Guangzhou city, a relatively developed district in China. The study may be relatively more helpful for diabetes educators in our clinic and other clinics in Guangzhou. The results of this study cannot be extrapolated to patients from other districts with different economic and health-care environments. Another limitation lies in its observational nature. Interventional research in this area remains to be carried out.
In conclusion, the study shown that adult patients with type 1 diabetes in our clinic had substantial SMBG information deficits, motivation obstacles, and skill limitations. These deficiencies accounted for a respectable proportion of the variation in SMBG frequency, which may provide potential-focused education targets for diabetes health-care providers.
Financial support and sponsorship
This work was supported by grants from the Sun Yat-sen University Clinical Research 5010 Program (No. 2007030), the Science and Technology Planning Project of Guangdong Province (No. 2014A020212065, No. 2015A030401034), and the Chinese National Natural Science Foundation (No. 81100556).
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We would like to thank all the doctors, nurses, technicians, and patients for their dedication to this study.
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Edited by: Li-Shao Guo
